Clinical diagnosis
Case 289
【Progress】
Case 1 is placed on no further examination, Case 2 is recommended ischemic functional test and Case 3 is recommended invasive cardiac angiography with interventional treatment if necessary.
【Discussion】
Coronary artery is numbered from #1 to #17 based on its bifurcation and function (1, 2). It is sometimes difficult to differentiate and do numbering because of its variation. Then, it is stressing to identify what numbering artery is the occlusive artery responsible cardiac ischemia. However, coronary artery is largely divided into three main arteries: right coronary artery, left anterior descending branch artery and left circumflex branch artery. According to coronary artery disease – reporting and data system (CAD-RADS) version 1 and 2 (3, 4), the numbering of coronary artery is not always necessary to document but coronary artery occlusive lesion is required to document largely to be present in which artery of these three artery. Namely, the lesion should exist in which artery of these main three arteries, indicating no need to document numbering of coronary artery.
CAD-RADS version 2 is created to meet further examination of ischemic cardiac function and treatment (4).
Based on CAD-RADS version 2 (4), interpret of occlusive disease is first to recommend calculate the number of plaques irrespective of mural calcification or not. Then, it leads to scoring of plaque volume; P1, mild amount, 2 or less 2, 1-2 vessels with mild mount of plaque; P2 moderate amount 3-4, 1-2 vessels with moderate amount; P3 severe amount, 3 vessels with moderate amount, 1 vessel with severe amount of plaque: P4 extensive eight or greater 2-3 vessels with severe amount of plaque. Further, of plaques, maximum stenosis rate is calculated; CAD-RADS 1, 1 – 24% minimum stenosis; CAD-RADS 2, 25 - 49% mild stenosis; CAD-RADS 3, 50 -69% moderate stenosis; CAD-RADS 4A, 70-99% severe stenosis; CAD-RADS 4B, 3 vessel 70% or greater in 3 vessels or > 50% in left main: CAD-RADS 5 extensive stenosis 100%.
CAD-RADS 1 and CAD-RADS 2 imply no need for further catheterization. CAD-RADS 3 implies need of cardiac function assessment. CAD-RADS 4A implies cardiac functional assessment or invasive coronary angiography, 4B implies invasive cardiac angiography. CAD-RADS 5 implies invasive cardiac angiography and viability assessment.
In Case 1, plaque amounts are 7 in 2 vessels indicative of P3 whose maximum stenosis reveal mild stenosis (25 – 49%) indicative of CAD-RADS 2. In Case 2 plaque amounts are 3 in 2 vessels indicative of P2 whose maximum stenosis reveal moderate stenosis (50 - 69 %), indicative of CAD-RADS 3. In Case 3, plaque amounts are 2 in 2 vessels indicative of P1 whose maximum stenosis reveal severe stenosis (70 - 99 %), indicative of CAD-RADS 4A.
【Summary】
We presented 3 cases with coronary artery occlusive diseases. CT angiography including volume rendered imaging, slab maximum intensity projection imaging and three dimensional angiography revealed CAD-RADS 2 in Case 1, CAD-RADS 3 in Case 2 and CAD-RADS 4A in Case 3. It is borne in mind that for interpreting coronary artery disease based on CAD-RADS version 2, first evaluation is to check number of plaques irrespective of calcified or non-calcified and making P score, second evaluation is to assess stenotic rate in each occlusive lesion and third evaluation is what overall findings meet classification of CAD-RADS.
【References】
1.Muriago M, Sheppard MN, Ho SY, Anderson RH. Location of the coronary arterial orifices in the normal heart. Clin Anat. (1997) 10:297–302.
2.Roberts WC. Major anomalies of coronary arterial origin seen in adulthood. Am Heart J. (1986) 111:941–63.
3.Cury, R. C., et al. (2016). “CAD-RADS: Coronary Artery Disease – Reporting and Data System.: An Expert Consensus Document of the Society of Cardiovascular Computed Tomography (SCCT), the American College of Radiology (ACR) and the North American Society for Cardiovascular Imaging (NASCI). Endorsed by the American College of Cardiology.” J Am Coll Radiol 13(2 Pt A): 1458 – 1466.
4.Cury, R. C., et al. CAD-RADS™ 2.0 - 2022 Coronary Artery Disease-Reporting and Data System: An Expert Consensus Document of the Society of Cardiovascular Computed Tomography (SCCT), the American College of Cardiology (ACC), the American College of Radiology (ACR), and the North America Society of Cardiovascular Imaging (NASCI). J Am Coll Radiol Available online 8 July 2022
2023.2.2